Initial experience of intrathoracic rib fixation using RibFix Advantage™ at a major trauma centre: operative technique and case series

Introduction

Chest wall injuries are a frequent consequence of blunt force trauma, representing a leading cause of trauma-related mortality. Among these, multiple rib fractures are the most frequently encountered, resulting in impaired ventilatory mechanics and chest wall instability, which significantly contribute to morbidity and mortality (1,2). Flail chest is defined as three or more sequential ribs fractured at multiple sites, resulting in paradoxical chest movement. Consequences of rib fractures and flail chest include pulmonary contusion, chronic pain, chest wall instability, deformity, atelectasis, acute respiratory distress syndrome, and death, which has been reported in 25% of thoracic trauma (3,4).

Risk factors associated with mortality include increasing age, pre-existing comorbidities, and an increased number of fractures (5-7). Pain-related splinting and impaired ventilatory function reduce effective secretion clearance, predisposing patients to pneumonia and other pulmonary complications, which are significant contributors to post-injury mortality (1,5). Additionally, displaced fractures may cause injury to adjacent soft tissue, pleura, and lung parenchyma. This leads to pneumothorax, associated vascular injuries, and haemothorax, which can become infected with consequences such as empyema and chronic lung trapping (1,8).

There has been a paradigm shift from the traditional conservative approach of rib fracture management towards operative rib fixation with the advancement in technologies and knowledge. Randomised control trials and case control studies have shown superiority of surgical stabilisation of rib fractures (SSRF) for reduction of displaced fractures in comparison to non-operative management, particularly in ventilated patients (9-11). This has led to a position paper for SSRF supported by the Chest Wall Injury Society (CWIS) for expert consensus of operative fixation (12). Benefits of surgical fixation have been reported with reduced length of stay in the intensive care unit (ICU), morbidity, pneumonia, time on mechanical ventilation, and need for tracheostomy in comparison to non-operative management (13). Moreover, long-term outcomes appear to favour surgical fixation, demonstrating improvements in chest wall mechanics, functional status, and pain control (14).

Video-assisted thoracoscopic surgery (VATS) has proven valuable in the management of chest trauma, with the most common indication being evacuation of haemothorax (15). VATS also facilitates the diagnosis and repair of significant intrathoracic injuries, such as diaphragmatic tears, lung lacerations, and herniations (16). As SSRF techniques continue to evolve, new technologies have enabled less invasive approaches, including intrathoracic rib fixation, which can achieve chest wall stability while allowing for a less invasive approach (17). With this case series, we aim to share our initial experience with intrathoracic SSRF (I-SSRF) to report our operative technique and learning points. We present this article in accordance with the SUPER and AME Case Series reporting checklists (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1696/rc).

Preoperative preparations and requirements

This study was conducted in accordance with the principles of the Declaration of Helsinki and its subsequent amendments. Informed consent was obtained from all patients prior to the surgical procedure and for publication purposes. The study protocol was approved by the hospital’s Research and Ethics Committee under registration number GF1001. The procedure was carried out at University Hospital Coventry and Warwickshire, a tertiary referral hospital and designated major trauma centre in the United Kingdom.

The procedure was carried out using the RibFix Advantage™ Intrathoracic fixation system (Zimmer Biomet, Warsaw, IN, USA), which includes short (60 mm) and long (90 mm) bridges, each with 23 mm locking posts, locking caps, 9.5 mm washers, and titanium guidewires. Additionally, a 4.0-mm surgical drill and a drill guide were utilised to create the access for the locking posts. Guide tubes (8 Fr) allow passage of titanium guidewires. To improve visualisation at the incision site for multiple fracture levels, a medium or large Alexis^® wound protector is used. A 10-mm high-definition 30-degree scope is used for thoracoscopic assessment and visualization, and an extra-small Alexis^® wound protector is utilized. Video-assisted thoracoscopic instruments are also utilised in this procedure.

For rib fixation, we advocate the earliest possible surgical intervention when feasible, recognizing that some patients may present with concomitant injuries requiring urgent management or may experience delays due to transfer from other facilities. Preoperative planning with computed tomography (CT) and 3-dimensional (3D) reconstruction is essential for determining the optimal surgical incision for rib fracture repair and identifying the most suitable site for scope insertion. We recommend planning VATS incision with adequate distance from the fracture site, as demonstrated in Figure 1. This allows good visualisation of the fracture and space for the internal plate to be fixed in place. Pre-operative planning importantly includes discussion with other trauma specialities if the patient has suffered multiple other traumatic injuries to determine treatment priorities and restrictions in patient positioning. Single-lung ventilation is essential; therefore, discussion with the specialist thoracic anaesthetic team is warranted. In cases where single-lung ventilation is not feasible, CO₂ insufflation or direct transthoracic placement may be required.

Figure 1 Preoperative planning with 3D CT reconstruction showing the incision site for rib fixation (red line) and VATS port placement (green oval) to ensure adequate intrathoracic visualization. 3D, 3-dimensional; CT, computed tomography; VATS, video-assisted thoracoscopic surgery.

Step-by-step description

Intrathoracic SSRF (I-SSRF) operative technique (Figures 2,3)

Figure 2 I-SSRF operative steps. (A) Palpation of displaced rib fractures for operative planning. (B) VATS port with Alexis^® wound protector. (C) VATS needling to plan adequate incision. (D) Drill guide placement. (E) Guide tubes advanced into the chest. (F) Guidewires passed through guidance tubes. I-SSRF, intrathoracic surgical stabilisation of rib fractures; VATS, video-assisted thoracoscopic surgery.

Figure 3 I-SSRF operative steps. (A) Titanium plate constructs passed through guidewires. (B) Plate can be adjusted to allow adequate reduction. (C) Screwdrivers are advanced externally along the guidewires and the bolts are securely tightened, whilst maintaining tension on the guidewires. (D) Guidewires are removed through the VATS port. (E) Locking screws on the external rib surface. (F) Fracture reduction shown internally. I-SSRF, intrathoracic surgical stabilisation of rib fractures; VATS, video-assisted thoracoscopic surgery.

Patients are placed in the left or right lateral decubitus position, depending on the operative site, with single-lung ventilation achieved via double-lumen intubation or bronchial blocker. A pillow or inflation cuff may be positioned at the level of the xiphoid process to improve exposure of the intercostal spaces; however, this step may be omitted to prevent further displacement of the fractures. Under general anaesthesia, the chest wall is explored to identify the fractures. A 3-cm lateral VATS incision is made to allow direct visualization of the rib fractures and to identify any associated intrathoracic injuries. Displaced ribs can be assessed intrathoracically, and the target area marked with a 21-G hypodermic needle. This technique of rib marking using a hypodermic needle through the chest wall has been described in other thoracic chest wall procedures utilising VATS technique (18). A muscle-sparing incision is made over the displaced rib fractures, and dissection achieves adequate exposure of the displaced fractures. We aim to utilise a minimally invasive 1.5 cm incision per rib fracture to facilitate adequate exposure. The use of a wound protector (Alexis^® retractor) facilitates access to adjacent ribs, allowing internal fixation at multiple levels through a single small incision (Figure 4). Elevation of the periosteum is undertaken using a periosteal elevator.

Figure 4 4 cm incision, which allowed adequate exposure and fixation of multiple levels of fractures.

RibFix Advantage™ Intrathoracic fixation system was utilised in all cases to achieve fracture reduction and fixation with titanium plate placement internal to the ribs. Marks are placed 1.5 cm away from the fracture. Placement of a drill guide with the pin placed superior to the rib surface is used to control drill depth and avoid injury to the neurovascular bundle. A drill 4.0 mm in diameter is utilised to create an opening on both sides of the fracture. Through the drill guide, guide tubes are advanced and then recovered in the chest and pulled through the VATS port. This step is repeated on each side of the fracture. Guide wires are placed through the tubes in order to feed the titanium bridge construct into the chest through the VATS port incision and pulled out through the holes on each side of the fracture. The plate can be adjusted to achieve adequate fracture reduction. Applying tension to the guide wires facilitates internal reduction of the fracture, enabling fixation with screws and locking caps placed on the external surface of the rib. Locking posts are cut flush to the screw.

Case series and representative case description

A total of 15 patients have undergone I-SSRF operative technique in our institution since May 2025–August 2025. All 15 patients were treated consecutively in our thoracic surgery unit using I-SSRF following admission for chest trauma in this period. Indications for surgical fixation included severe or refractory chest pain (despite optimal analgesia), respiratory compromise, flail segment or chest on examination, rib clicking, and haemothorax. We utilised a prospective database to document this cohort’s demographics, intrathoracic injuries, operative procedure, and early outcomes, including length of stay, post-operative ventilatory requirements, and reported complications. All patients requiring operative fixation in this timeframe underwent intrathoracic SSRF. The median age of this cohort was 57 [interquartile range (IQR), 46–68] years, including 10 males and 5 females. Nine patients had comorbidities, with hypertension being the most common. The most frequent mechanisms of injury were falls from height, followed by road traffic collisions. Timing of traumatic injury to surgery was variable, with a median of 3 (IQR, 3–7) days, with some patients requiring transfer from other district general hospitals to our major trauma centre after initial failed conservative management of chest injuries. Table 1 illustrates patient demographics, mechanism of trauma, and associated intrathoracic injuries. The median length of hospital stay for the 15 patients was 5 (IQR, 4–6) days. The only reported complication was one patient treated for a wound infection with antibiotics. Table 2 shows operative thoracic interventions and the postoperative course. We describe 3 of the 15 cases with various degrees of complexity.

Introduction of first case of I-SSFR

A 58-year-old lady was admitted following a fall down a flight of concrete stairs ten days earlier, which occurred while she was abroad. Injuries sustained included right 8^th and 9^th rib fractures at the costochondral junction and a posterior 10^th rib fracture. Clinical assessment did not reveal a flail chest; however, the patient reported significant pain due to clicking in the lower right posterior rib. The decision was made to proceed with I-SSRF for pain management. We chose this as the first case to perform, recognizing a case with less complexity of multiple displaced fractures without extensive other injuries. No intra or postoperative complications were encountered with operative time of 68 minutes, and the patient was discharged on the 3^rd postoperative day following single rib internal stabilisation with good pain relief from the procedure, with no further reported clicking.

A case of multiple intrathoracic injuries

An 84-year-old man was transferred from a district general hospital eight days after sustaining a blunt thoracic trauma from being kicked by a horse. He was admitted to the ICU requiring ventilatory support and pain management with epidural placement. He was transferred to our trauma centre for surgical management after failed conservative management with worsening respiratory compromise. Injuries included left 3^rd to 10^th rib fractures with significant displacement, left large pneumothorax and haemothorax requiring intercostal drain insertion. Intraoperative assessment showed a large clotted haemothorax, displaced fractures with lung parenchymal injury, and disruption of the diaphragm with herniation of omental fat. Washout of clotted haemothorax of 1 litre of blood was performed. A 5-cm incision was made to achieve adequate access to 3 level ribs, and laterally, ribs 5 to 7 were reduced and plated internally. Following general surgery consultation, the decision was made to reduce the hernia contents via a thoracic approach and to close the 5 cm diaphragmatic defect using Ethibond sutures in a mattress fashion, reinforced with Teflon pledgets. The defect was approximated without the necessity for patch closure. This gentleman recovered very well postoperatively and, following an overnight stay in the ICU, he was stepped down to the ward. He required rehabilitation with physiotherapy and was medically fit to be discharged 5 days following surgery after being treated for a minor wound infection (Figure 5).

Figure 5 Pre-operative 3D CT reconstruction and post-operative chest X-ray images. (A) Left posterior and lateral 3D reconstruction CT. (B) Post-operative chest X-ray. 3D, 3-dimensional; CT, computed tomography.

A case of hybrid internal and external rib fixation

A 53-year-old male was admitted following a motorbike road traffic collision. He suffered bilateral rib fractures, left 2^nd to 10^th and right 6 and 7, with significant pain, limited mobility, and chest wall instability. Other injuries sustained included a displaced left clavicle fracture, scapular fracture, and C7 spinous process fracture. VATS assessment revealed significantly displaced anterior fractures of the left 4^th to 6^th ribs, as well as posterior fractures of the 5^th and 6^th ribs. A 1.2-litre haemothorax was also evacuated. Anterior fractures were reduced and fixed utilising RibFix Advantage™. Posteriorly, a shorter RibFix Advantage™ plate was used with applied curvature for fracture reduction and fixation, which we have found effective, particularly in these posteriorly located fractures. An external RibFix Blu™ thoracic fixation plate was used for reduction of the 5^th rib posteriorly, due to the rib contour altering following placement of internal plate anteriorly, which achieved adequate reduction with good results. Despite this patient’s significant injuries, he was discharged from hospital 5 days following his procedure with no complications (Figure 6). This case highlights the advantages of using of both internal and external fixation approaches in complex cases with anterior and posterior displaced fractures, utilising minimally invasive incisions.

Figure 6 Pre-operative 3D CT reconstruction and post-operative chest X-ray images of hybrid fixation case. (A) 3D reconstruction images showing anterior and posteriorly displaced left rib fractures. (B) Post-operative chest X-ray with both anterior and posteriorly located plates. 3D, 3-dimensional; CT, computed tomography.

Postoperative considerations and tasks

Although SSRF provides improved pain control, it is also important to implement postoperative pain management strategies. Patient-controlled analgesia and, when feasible, placement of a paravertebral catheter can facilitate faster recovery. Postoperative complications were determined by the presence of respiratory deterioration, pneumonia, wound infections, bleeding, or any need for reintervention. Chest physiotherapy daily is fundamental to aid recovery and reduce the risks of post-operative respiratory complications. In polytraumatised patients, elective admission to the ICU for brief ventilatory support may aid convalescence in those with multiple thoracic injuries. Follow-up for our patients includes, in selected cases, wound review at 5–7 days after discharge and outpatient clinical assessment 6 weeks postoperatively with routine chest x-ray imaging.

Tips and pearls

During the preliminary cases, careful patient selection is important, favouring those with uncomplicated fractures, such as single-site fractures, to allow the surgical team to become familiar with the technique. As shown in our hybrid case, this fixation system can be used in conjunction with external fixation in selected complex cases. 3D CT reconstruction is extremely beneficial for preoperative planning, including identifying the levels requiring fixation and determining the incisions for surgical access. For posteriorly sited fractures, using the smaller 60 mm plate and manually adding a slight curvature facilitates better alignment with the natural rib contour. In left-sided fractures, be mindful when creating the VATS port incision of the heart underlying, as this can create difficulty in instrumentation and risk other injury. In cases with displaced fractures where the pleura obstructs drilling, remove the drill guide and, under direct visualization, carefully continue inserting the drill through the hole. Positioning of the fixation plate with the guidewires is performed carefully to prevent wire twisting. We recommend first pulling through the distal wire, followed by the proximal wire to minimize the risk of plate rotation, and adjusting the plate position as necessary using a VATS grasper. For wire extraction, we advise using a long grasper to avoid kinking or damaging the wires. Tightening each screw incrementally while maintaining tension on both sides of the fracture allows for better fracture reduction. Overtightening locking caps should be avoided as this may cause injury to the rib.

Discussion

Rib fracture management has evolved over time, with the earliest cases of reduction and rib stabilisation performed using suture and wire cerclage in the 1900s (19). Evolution of concepts led to external plating mainly through thoracotomy incisions to achieve rib stability for respiratory mechanisms and pain management. More recently, there has been a shift toward minimally invasive, muscle-sparing approaches that allow for smaller incisions. The technique described in our series represents a further step in this evolution, offering a less invasive method of rib fixation with effective exposure and stabilisation.

The development of novel technologies has advanced trauma management significantly, with the first described case of thoracoscopy used for chest injury to assess diaphragmatic injury in 1976 by Jackson and Ferriera (20). This concept has allowed visualisation of the chest cavity and identification of other injuries that would lead to increased morbidity if not treated. As demonstrated in our case series, the majority of patients required additional procedures, including haemothorax evacuation, lung injury repair, and diaphragmatic injury repair. If unrecognised or left untreated, these associated injuries could have been life-threatening.

There have been a small number of studies directly comparing extra-thoracic and intrathoracic fixation. These studies have been mainly retrospective cohort studies (21-24). Cadaveric research has demonstrated superior construct stiffness with intrathoracic plating compared to extrathoracic methods (25). Furthermore, recent studies have reported that the intrathoracic approach is associated with reduced analgesic requirements, blood loss, chest tube duration, shorter operative times, and shorter hospital stays (21-24). Additionally, shorter incision lengths and faster mobilisation times have been observed, supporting the reduced invasiveness of intrathoracic plating (22). In comparison with a reported case series on this technique with a similar patient demographic we report a lower average postoperative length of time to be medically fit for discharge at 5 days compared to 11 days. We also report a lower ICU length of stay (26). In our cohort, one patient presented with respiratory failure prior to surgical fixation and required invasive ventilation before surgery. As expected, this patient required a prolonged ICU stay for ventilatory support and postoperative weaning. Patients in respiratory failure preoperatively may be at increased risk, as this procedure requires a period of single-lung ventilation. In such cases, inadequate oxygenation during single-lung ventilation may represent a limitation of the technique. However, the use of CO₂ insufflation and direct transthoracic plate placement can be considered as alternatives.

As in our described cases, we advocate use of 3D reconstruction imaging for operative planning. This allows assessment of the extent of bony injuries, planning of incision sites for access, the number of ribs requiring fixation, and the degree of misalignment. Other studies have assessed the use of 3D reconstruction and creation of 3D printing models to aid planning for rib fixation in such cases (27). In our series, the average number of fractured ribs per patient was seven, whereas the average number of surgically plated ribs was three. Preoperative CT planning enabled identification of the ribs with the greatest misalignment for fixation, while intraoperative clinical judgment was also important to target the most significantly injured ribs. The discrepancy between fractured and plated ribs may also reflect the limited accessibility of fractures underlying the scapula, fractures located too superiorly to be fixed, or situations in which chest wall stability could be achieved without the need to fix all fractures.

Several patients in our series sustained fractures at multiple sites, including lateral and posterior rib fractures, where the intrathoracic approach proved particularly advantageous. In such cases, we found that contouring titanium plate constructs to match the natural rib curvature facilitated adequate reduction and fixation, especially in posterior locations, as in case 5. In our early cases, we were able to achieve adequate exposure across multiple rib levels using minimally invasive incisions. Fractures involving three to four rib levels were reduced through 4–5 cm muscle-sparing incisions. The use of the Alexis^® wound protector further enhanced access to adjacent rib levels through a single incision. We found this to be a safe and effective technique for rib fixation, with a relatively straightforward learning curve. It is difficult to determine whether the learning curve influenced outcomes in our study, given the small sample size and the fact that this represents only our initial cases. Furthermore, the consultant surgeons at our institution each have more than 13 years of experience in uniportal VATS and are highly experienced with extrathoracic plating. Both also received the in-person training required to utilize the I-SSRF kits.

We recognize several potential limitations of the described technique. Single-lung ventilation may not be feasible in all patients, particularly those with preoperative respiratory compromise, although alternative strategies are available. Visualization and access can be challenging for posterior, paraspinal, or subscapular fractures. Difficulties may also arise with comminuted or oblique fractures, as well as with costochondral or costosternal injuries, which were not included in our case series. In addition, the learning curve for I-SSRF has not yet been fully characterized and may limit its reproducibility. Finally, while the availability of the instrumentation set may vary between thoracic units, it is important to note that our series describes the use of a standardized, commercially available kit for intrathoracic plating with ease of implementation.

The limitations of our study include the small sample size and the reporting of early postoperative rather than long-term outcomes. In addition, the absence of a control group limits the generalizability of our findings. We plan to expand the cohort and include longer-term follow-up in future studies, as well as to determine comparative outcomes with extrathoracic plating.

Conclusions

Our early experience demonstrates that intrathoracic rib fixation using RibFix Advantage™ can be implemented safely and effectively at a major trauma centre, with straightforward preparation and integration into the theatre team workflow. To our knowledge, these are the first reported cases of intrathoracic rib fixation using this technique in Europe. Unlike previous I-SSRF studies, our study reports outcomes with the first standardised widely available intrathoracic fixation kit, enabling the potential for wider adoption. In addition, dedicated training resources are available to familiarize surgeons with this technique, thereby easing the learning curve for those in training or already experienced in rib fixation.

This approach offers several advantages in the context of chest trauma. VATS allows direct assessment and repair of intrathoracic injuries that may be missed on CT imaging, such as diaphragmatic tears, which were identified in a notable proportion of our cohort. Internal rib contour alignment facilitated good fracture reduction and contributed to improved ventilatory mechanics. Furthermore, smaller, muscle-sparing incisions provided adequate pain control and supported faster recovery, with shorter hospital stays.

Future prospective randomized trials are warranted to more clearly define the benefits of intrathoracic compared with extrathoracic SSRF, not only in terms of clinical outcomes but also in patient-reported measures such as quality of life and long-term pain control.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER and AME Case Series reporting checklists. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1696/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1696/prf

Funding: The article processing charge for this manuscript publication was funded by Zimmer Biomet.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1696/coif). L.A.H.A. reports he is a proctor for Zimmer Biomet, and receives funding from Zimmer Biomet for the article processing charge for this manuscript. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted following the recommendations of the Declaration of Helsinki and its subsequent amendments. Informed consent was obtained from all patients before the surgical procedure and for the publication. The study protocol was approved by the hospital’s Research and Ethics Committee under registration number GF1001.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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